02 Mar Waitlist Management: Challenges for the New Era
Active and effective management of transplant center waiting lists has never been more important as transplant outcomes reporting shifts away from an exclusive focus on post-transplant outcomes toward a more robust assessment of center performance–which includes pre-transplant metrics as well.
The new SRTR reporting website highlights transplant rate and waitlist mortality rates, demonstrating differences in center performance for patients who can choose among transplant providers. The UNOS membership and professional standards committee has considered several metrics to identify centers with poor pre-transplant outcomes. This focus on pre-transplant outcomes creates an absolute requirement that centers develop and maintain a robust system to continually monitor and re-evaluate listed patients.
The complexity of waitlist management is greatest for renal transplant programs. As waiting times become longer, centers grapple with larger numbers of patients who have more co-morbidities and longer exposure to chronic dialysis times. In some regions, the proportion of patients transplanted at five years still does not exceed 25%, resulting in high rates of mortality and delisting. At transplant, the impact of obesity, diabetes, coronary artery disease, renal osteodystrophy on early post-transplant outcomes and case cost is profound. While some centers suggest these issues are “out of our control”, they are, nevertheless, a reality in today’s competitive transplant environment.
What successful strategies exist to improve waitlist outcomes and mitigate this risk? While some centers have chosen to reduce access to the waiting list and become more conservative in listing practices, this will likely result in lower transplant volumes and reduce access to transplant for deserving and acceptable recipients. A more effective strategy is the active management of patients who are waiting on the list:
Patients need to understand that they are part of the solution and must actively participate in their care. Through frequent contact, centers can motivate patients to maintain a healthier lifestyle prior to transplant, remain compliant with dietary and phosphorus binder guidelines, and limit weight gain. Patients need clear instructions on what behaviors will result in removal from the waiting list as well as socioemotional support to assist them with the difficult task of compliance even when transplantation seems a distant possibility.
- Careful and consistent cardiac screening
As patients are maintained on dialysis, the impact on cardiovascular health is profound. Thus, centers should establish standardized protocols to assess and then re-assess cardiovascular health.1 This frequently requires education of referring cardiologists, who are asked to provide “cardiac clearance” for other non-cardiac procedures. Transplant is different, however, as the question asked by transplant professionals is whether the patient has lesions which are likely to progress or prove fatal within five years, not whether the transplant can be safely performed at all.
- Cancer testing and close follow-up
Routine screening for malignancy (colon, breast, prostate) among transplant recipients is crucial.2 The incentive for patients to maintain currency with tests once they are on the list is less than when they are initially listed. Transplant programs have to assume responsibility for arranging these procedures, as failure reflects on our outcomes.
- Reducing the percentage of the patients who are listed as inactive or Status 7 3
These patients increase costs, consume staff time, and do not result in transplant volume. Centers should develop strategies to continuously evaluate the rationale for keeping patients inactive on the waiting list and set target dates for reactivation.
- Frequent contact
Once a year visits are insufficient to identify candidates with disqualifying conditions and maintain an active waiting list. In-person evaluation twice per year, as well as periodic contact through electronic communication, can rapidly increase the proportion of the waiting list who are ready for transplant.
Transplant center waitlists have been described as our “inventory” at Waitlist Management. We invest substantial resources in evaluation, listing, and education, which pays off with more transplant procedures and better post-transplant outcomes. However, like all inventory, there is a cost of maintaining it. Transplant programs need to educate senior health leaders regarding the value of this investment.
- Lentine KL, Villines TC, Axelrod D, et al. Evaluation and Management of Pulmonary Hypertension in Kidney Transplant Candidates and Recipients: Concepts and Controversies. Transplantation. 2017;101(1):166-181. Available at: https://www.ncbi.nlm.nih.gov/pubmed/?term=26985742.
- Dharnidharka VR, Naik AS, Axelrod D, et al. Clinical and Economic Consequences of Early Cancer after Kidney Transplantation in Contemporary Practice. Transplantation. 2016 Aug 3. Available at: https://www.ncbi.nlm.nih.gov/pubmed/?term=27490413.
- Grams ME, Massie AB, Schold JD, et al. Trends in the Inactive Kidney Transplant Waitlist and Implications for Candidate Survival. Am J Transplant. 2013;13(4):1012-8. Available at: https://www.ncbi.nlm.nih.gov/pubmed/?term=23399028.